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Growing Healthy podcast


Sep 8, 2018

AP: Welcome to the Growing Healthy Podcast.  Today we are fortunate to have Dr. Kelsey Mills with us to talk about Menopause!!  Dr. Mills is an obstetrician and gynecologist who has extra training in the Hot topic of Menopause!  Thanks for joining us Kelsey!
 
 KM: Thanks Alicia, it is my pleasure to chat with you today!  This is a topic that can get women all fired up! 
 
 AP: Why don’t we start with the basics; what is menopause? 
 
 KM: That’s a great place to start.  Menopause is defined as the permanent absence of menstrual periods for one year, in the absence of other reasons for a period to stop, such as pregnancy. We have had a couple women tricked into thinking they were in menopause when in fact they were pregnant!  
 
 AP:  What a surprise that would be!!! Can you tell us a little more about Menopause.  
 
 KM: The average age of menopause in Canada is 51.4 and anything after 40 is in fact in the realm of normal. If a woman enters menopause under the age of 40, we search for other diseases, or reasons why that could happen. In natural menopause, a woman stops having periods because her ovaries have essentially used up their pool of eggs (oocytes) and are no longer ovulating each month. Therefore, there isn’t an episode of bleeding that follows ovulation, so all bleeding stops. When women don’t ovulate anymore, there are much lower levels of circulating estrogens in their body which may or may not result in menopausal symptoms. 
 
 AP:  But the transition is not necessarily an on/off switch is it....
 
 KM: Nope...it sure isn’t!  On average, women start to experience symptoms of perimenopause for 4-5 years prior to not getting a menstrual period any more.  These symptoms can include irregular or erratic cycles, cycles that fluctuate in heaviness (one month light, one month very heavy), mood changes, hot flashes, night sweats, sleep disturbances and vaginal dryness.   
 
 AP: I often have women coming in around that time with musculoskeletal complaints as well....
 
 KM: There are some other common concerns that happen around the time of menopause and certainly increase with aging, like “brain fog”, memory changes, hair loss, weight gain, and muscle and joint pains.

 AP:  So lets talk about the menopause-specific symptoms a bit more and how we can manage them.  
 
 KM: Great.  So I find that the symptom that bothers women the most, are what we call “vasomotor symptoms” which include the hot flashes and night sweats. We know that about 80% of women in the menopausal transition experience hot flashes, but unfortunately only about 20% of those women will seek medical attention for them. Studies have shown that women find it difficult to discuss menopausal concerns with their primary care providers, and in particular find discussing vulvo-vaginal or sexual symptoms to be the most challenging. But back to hot flashes, these are generally described as a feeling of heat starting in the chest and then spreading over the upper body, face and neck. They can be accompanied by heart palpitations and sweating, and they generally last for 2-4 minutes. Hot flashes are so interesting, because some women never experience them, and some women will flash several times an hour in menopause. Hot flashes can also be different woman to woman; some women describe a prickling or skin-crawling sensation, some women describe a sense of impending doom! This is serious stuff. Menopause researchers used to believe that hot flashes only lasted for 4-5 years, but we now know that they can last much longer, perhaps 8 years on average, and some women will flash for the remainder of their life.  
 
 AP: Are there any factors that can make it more likely that women will have worse hot flashes? 
 
 KM: Well we know obesity and smoking both increase the risk of hot flashes. Interestingly, certain ethnic backgrounds, such as being of African descent, may make a woman more likely to have hot flashes. 
 
 AP: Hot flashes can happen at night as well....often drenching beds with sweat etc.  and this leads into our next symptoms of menopause....sleep disturbance!  We know that about 40% of women struggle with sleep in the menopause transition - this can be related to hot flashes, or our next topic....mood changes - namely depression.  They can also be related to things like restless legs or sleep apnea - so please make sure you talk to your family doctor if you are having sleep disturbances as there may be some testing we need to do and something we can help you with!  
 
 KM: It is true...there are so many interconnected pieces within menopause, but we can't blame everything on it!  The mood changes can often be attributed to the perimenopausal and early post menopausal time, especially in women who have not had mood disturbances before, and in these women, we often see it improve 1-2 years after menopause.  Women with pre-existing anxiety and depression are at the most risk for worsening mood issues during the menopausal transition. Probably the number one descriptor of mood changes that I hear is an increase in a women’s “irritability”. But the midlife can be a very stressful time for women, and there are many reasons for mood changes in the midlife which may not be all attributable to hormonal changes.

 AP: Vaginal dryness is often a complaint women have with menopause, can you speak about that a bit? 
 
 KM: Absolutely. This is a really important topic that I wish women felt more supported to discuss. Estrogens play an important role in our bodies and women can make several different kinds of estrogens. Tissues in a women’s vulva, vagina, lower urinary tract and bladder are very sensitive to the effects of estrogens. When those estrogens are withdrawn in menopause, this can result in something we term “genitourinary syndrome of menopause” which is a fancy name for when all those tissues become drier and less elastic. This can result in itching, bleeding, having to urinate frequently or urgently, getting recurrent urinary infections, and having pain with sexual intercourse. Unlike many other menopausal symptoms, the genitourinary symptoms often start later into menopause and will progress as a woman ages.

 AP: And I also think it is important to note, that these symptoms, especially the itchiness and pain, are not always simply due to menopause, so again it is important to see your care provider to ensure it is not something else causing this!  
 
 KM: Indeed!  These changes can be very uncomfortable and distressing for women....so please do not suffer unnecessarily...come talk to us...because we can help!!! And I want to take this moment to point out that although some women may bleed in menopause because of tissue dryness, post-menopausal bleeding is never normal and other sinister causes must be ruled out. Please speak to your doctor if you are menopausal and start bleeding again. Your doctor can help you with investigations to rule out worrisome causes of post-menopausal bleeding, like certain cancers.
 
 AP:  That’s a great reminder. Well lets chat about what we can do to help women going through menopause….
 
 KM: First and foremost let’s talk about lifestyle modifications that women can do to help manage the menopausal transition.  Anything that cools us down can help with hot flashes - having the room at a lower temperature, using a fan, using moisture wicking sheets or clothes, dressing in layers that can easily be removed and avoiding triggers like spicy food or stress can all help. Alcohol is a huge hot flash trigger for many of my patients. And alcohol contains a lot of empty calories, so cutting back can help with weight reduction and vasomotor symptoms. We also know that excessive alcohol consumption is a risk factor for breast cancer. So that’s another important reason to stop excessive drinking. Back to the notion of weight loss, if a woman is carrying extra weight, losing weight may reduce menopausal symptoms. Another very important point is that quitting smoking can have a large impact on vasomotor symptoms, bone health and overall health for women.
 
 AP: Beneficial for menopause and beyond!!!  Other changes that can help with mood changes, joint achiness and sleep disturbance include staying well hydrated, getting regular exercise, eating healthily and maintaining good sleep hygiene. Pulling in your support system, through what can be a challenging period in your life, is never a bad idea!! Mindfulness-based stress reduction is another tool that many women going through menopause, or other stressful times, find to be very helpful!
 
 KM: Indeed...but most women who come to see me are suffering more than these measures can help, and that is why we often have a conversation about medications. 
 
 AP:  My understanding is that when it comes to medications, you treat based on symptom severity, so not every treatment plan is the same...is that correct?
 
 KM: Exactly. Women are so unique. Remember that there are some menopausal women who have never had a hot flash, and some who suffer hourly!   If someone has vulvo-vaginal issues, and no other symptoms, then I will treat that, but if a woman has multiple issues the treatment plan might be much different!
 
 AP: Shall we talk about treatment then?  
 
 KM: Yes, let’s do it. The simplest symptom to treat is vaginal dryness.  Using a good lubricant with intercourse can be enough for some women’s concerns, but others may benefit from a vaginal moisturizer or local vaginal estrogen to help with their symptoms.  Vaginal estrogens in Canada can come in the form of a cream, a vaginal suppository, or a vaginal ring that is worn daily for 3 months. Local estrogens are extremely safe and there is very minimal systemic absorption of these medications. In general, vaginal estrogens are safe for all women. They do not carry an increased risk of blood clot, or stroke. If a woman has had breast cancer, then this is a bigger conversation and I encourage her to discuss the role of local estrogens with her gynecologist and oncologist. 
 
 AP: So I have heard lots about vaginal rejuvenation.....lasers and vaginas....seems like a dangerous combination....
 
 KM: Using lasers to treat vulvo-vaginal symptoms is a relatively new player in the menopause realm. And this is different from using lasers or surgery for cosmetic enhancement, or “rejuvenation”, of the vulva and vagina. I strongly advise women against cosmetic changes their vulva and vagina. But that is another topic for another day!  Back to menopause, there is ongoing research looking into the safety, efficacy and long-term consequences of using a laser to treat vaginal symptoms, such as dryness, in menopause. Currently, vaginal laser treatments are not covered by Pharmacare or MSP, so women pay privately to use this device.  I look forward to seeing further studies in this area so I can help women decide if investing in this treatment is appropriate and safe for them. 

 AP: So what if women have hot flashes as well?  Will the vaginal estrogen help those?  
 
 KM: Good question Alicia. Hot flashes are treated with either hormonal or non-hormonal systemic medications.  If hot flashes or night sweats are bothering the woman, then we will have a discussion around treatment options.  The most common treatment is an estrogen and progesterone.  There are certainly some women who should not take these medications for medical reasons, which is one of the reasons it is so important to have a good conversation with your care provider prior to starting any medications!  
 
 AP: Now you said estrogen and progesterone....isn't just estrogen the problem?  
 
 KM: In general, menopause experts believe that vasomotor symptoms are best treated with systemic estrogen. But, if we give a woman with a uterus only estrogen, we increase her risk of endometrial, or uterine cancer. The endometrium is the lining of the uterus that sloughs off every month when a woman has a period.  The reason that it sloughs off, and just doesn’t keep growing and growing is progesterone.  So to protect the lining of the uterus from thickening into a potential cancer, we use progesterone to keep the endometrium thin and healthy. 
 
 AP: I have it on good authority that progesterone can help with sleep as well! 
 
 KM: Certain forms, like micronized progesterone, are better for this than others! Many women find progesterone to be sedating, and so I always recommend that women take their progesterone at night before bed.
 
 AP: So what is the goal with Hormone therapy? 
 
 KM: Our goal is to use the lowest dose, for an appropriate duration, to manage a woman's symptoms. This is individualized based on the woman’s symptoms. 
 
 AP: So you are not trying to get to a certain number in their hormone level?  
 
 KM: No...in fact we know that symptoms are not correlated with blood hormone levels, and I explain that to my patients by saying that a woman who has terrible hot flashes, and a woman who doesn’t know what a hot flash feels like, may have the same hormone levels! So we individualize the amount of hormone that women need (or don’t need!) based on how feel her symptoms are being controlled.

 AP: So why are some practitioners checking levels, and compounding creams specific to those numbers....
 
 KM: That’s an interesting question Alicia. Compounding hormones refers to mixing hormones in a specific base or oral preparation and then applying or ingesting those hormones. I worry about what exactly my patients are receiving when those hormones are mixed, because unlike pharmaceutical grade hormones (like pills, patches, or gels), no one is doing testing on those creams to check for components, quantities, purity, or to do batch testing. We also know that progesterone is not absorbed well across the skin, so I have major concerns when my patients come to me on progesterone creams and estrogen. No major professional organization advocates for the use of compounded hormones. Often compounded hormones are very expensive as well. 
 
 AP: So save your money and buy a new pair of shoes? 
 
 KM: Or hormones that work!
 
 AP: Back to business.....So how can the estrogen and progesterone be taken? 
 
 KM: Well, once a woman identifies that she would like treatment for her vasomotor symptoms, we first consider reasons why it may not be safe to take systemic hormones. Although hormone therapy is extremely safe, we know that in certain cases, using menopausal hormone therapy may increase women’s chances of a blood clot, stroke and breast cancer. This is particularly true of older women, for example, over the age of 60 who have multiple health problems. After evaluating these risks, we generally prefer transdermal estrogen, which is estrogen that is given through the skin in a gel or patch. We believe that this lowers the stroke and blood clot risk associated with estrogens. Most of my patients (if they have a uterus), will use a micronized progesterone to protect their uterus and help with sleep. The exact doses and types of hormone therapy are often individualized to the woman.

 AP: So we know that the HRT can help with some of the mood disturbance, but what if that is the main complaint as opposed to hot flashes?  
 
 KM: Well this is a topic you are probably better at managing than I am!! Treat the mood disturbance!! Although there are a few antidepressants that have shown some efficacy in improving hot flashes as well, so if women are suffering from mood disturbance and hot flashes and are not able to take HRT for some reason, we will try one of these medications to help manage both.  These medications include Paroxetine, Venlafaxine and Desvenlafaxine.  Now if you are on an antidepressant and not significantly affected by hot flashes, I would not switch to one of these, but if you have hot flashes, and your doctor is talking about starting an antidepressant, you could consider starting with one of these. Mood changes in menopause are not an indication for starting hormone therapy.  
 
 AP: Right, and remembering managing any mood disturbance the best place to start is talking and lifestyle optimization!  So talk to your doctor, talk to a counsellor or friend if possible, pull in your support system.  Get outdoors and exercise, make sure you are following a healthy way of eating, staying hydrated and minimizing alcohol.  
 
 KM:  Before we wrap up I just wanted to chat a bit about "natural/herbal" medication in menopause care because this is something I see a lot of. In general, I tell women that if they are using a herbal supplement and they find it helpful, then it is likely a fairly low risk thing to do. The studies show that most herbal supplements in menopause have a strong placebo effect, and women generally find their symptoms return around the 3 month mark. I see a lot of women who have tried all of the herbal supplements and not had relief of their symptoms. I once had a patient come to my office with a laundry basket full of supplements! She had tried everything, and was still having terrible hot flashes. This is common and your care provider can help you discuss medical options to help manage your symptoms more effectively. 

 AP: Great!  Well thanks for coming and chatting about Menopause with me....something to look forward to in the coming years!! 
 Keep on Growing Healthy.